Delayed escalation and inadequate fluid monitoring
Cwm Taf Morgannwg University Health Board received 2 coroners' reports about this hazard between 9 Mar 2020 and 28 May 2024.
They came from 2 different coroners. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
“(4) The failure at triage to escalate this referral to seeing a doctor within 10 mins of admission.”
Original on judiciary.uk ↗ Cwm Taf Morgannwg University Health Board responded, stating 5 specific actions.Response (PDF) ↗
“Review and provide definite warnings (oral and written) of sepsis when consenting patients to TRUS, and upon their discharge.”
Stated timescale: 11 March 2020
“We can confirm that a single leaflet, which is produced by the British Association of Urological Surgeons (BAUS), is now used, which states that patients should expect to go home on the same day, with no specific time scales given.”
3 more stated actions in the Promises tab.
- 4 years 3 months laterClosely relatedConfidence 0.90 · higha different coroner
“The Health Board accepted that significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts”
Original on judiciary.uk ↗ Cwm Taf Morgannwg University Health Board responded.Response (PDF) ↗
- All reports to Cwm Taf Morgannwg University Health Board
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2020 → 2024Clara Winter4 years 3 months after Darren Goddard · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight delays in recognizing patient deterioration and escalating care promptly. The earlier report focuses on triage escalation within 10 minutes, while the later report stresses timeliness of escalation and fluid balance monitoring on surgical wards.
Darren Goddard · 9 Mar 2020
“(4) The failure at triage to escalate this referral to seeing a doctor within 10 mins of admission.”
Original on judiciary.uk ↗ Clara Winter · 28 May 2024
“The Health Board accepted that significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Further training of Triage nursing staff and doctors of the sepsis 6 bundle and =e} Score (NEWS) documentation, escalation and the implementation of the Sepsis 6 bundle.”
Stated action · timescale: 11 March 2020
“Review and provide definite warnings (oral and written) of sepsis when consenting patients to TRUS, and upon their discharge.”
Stated action
“We can confirm that a single leaflet, which is produced by the British Association of Urological Surgeons (BAUS), is now used, which states that patients should expect to go home on the same day, with no specific time scales given.”
Stated action · timescale: ongoing (held on hold due to COVID-19)
“Further training of Triage nursing staff and doctors of the sepsis 6 bundle and =e} Score (NEWS) documentation, escalation and the implementation of the Sepsis 6 bundle.”
Stated action
“will also ensure that point of care testing for venous blood gases is introduced in order to identify abnormal lactate results, which are key to the early identification of sepsis.”
Stated action
“The learning from your report and the University Health Board's own investigations has been shared with individual staff, and also across the organisation via the Health Board's Listening & Learning Feedback Newsletter.”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Cwm Taf Morgannwg University Health Board at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2020 → 2024 | 0.68 | 0.03 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.